Interhospital transport to paediatric intensive care by specialised staff: experience of the South Thames combined transport service, 1998-2000

The South London Combined Transport Service retrieved 1536 children aged 1 month to 16 years to paediatric intensive care (PIC) units usually in south London, over a 2.5 year period. Eighty one per cent of cases were for general PIC, the specialist cases being mainly cardiac and neurosurgical. The service commenced as part of a national framework for improved PIC and offers children with complex needs a safe specialist transfer. Clinician and parental satisfaction with the service appears high, although there are considerable service pressures. Intensive care beds were successfully located, helping to reduce fragmentation of PIC for this population.     

Interhospital transport to paediatric intensive care by specialised staff: experience of the South Thames combined transport service, 1998-2000.

The South London Combined Transport Service retrieved 1536 children aged 1 month to 16 years to paediatric intensive care (PIC) units usually in south London, over a 2.5 year period. Eighty one per cent of cases were for general PIC, the specialist cases being mainly cardiac and neurosurgical. The service commenced as part of a national framework for improved PIC and offers children with complex needs a safe specialist transfer. Clinician and parental satisfaction with the service appears high, although there are considerable service pressures. Intensive care beds were successfully located, helping to reduce fragmentation of PIC for this population.     

Neurocritical care of high‐risk infants during inter‐hospital transport

The centralisation of neonatal intensive care in recent years has improved mortality, particularly of extremely preterm infants, but similar improvements in morbidity, such as neurodevelopmental impairment, have not been seen. Integral to the success of centralisation are specialised neonatal transport teams who provide intensive care prior to and during retrieval of high‐risk neonates when in‐utero transfer has not been possible. Neonatal retrieval aims to stabilise the clinical condition and then transfer the neonate during a high‐risk period for patient. Transport introduces the hazards of noise and vibration; acceleration and deceleration forces; additional handling and temperature fluctuations. The transport team must stabilise the infant fully prior to transport as when on the move they are limited by space and movement to effectively attend to clinical deterioration. Inborn infants have better neurodevelopmental outcome compared with the outborn and aetiology of this seems to be multifactorial with the impact of transport itself during critical illness, remaining unclear. To improve the neurological outcomes for transported infants, it seems imperative to integrate the advancing intensive care neuromonitoring tools into the transport milieu. This review examines current inter‐hospital transport neuromonitoring and how new modalities might be applied to the neurocritical care delivered by specialist transport teams.     

Improved neonatal survival and outcomes at borderline viability brings increasing ethical dilemmas

With improvements in neonatal intensive care over the past five decades, the limits of viability have reduced to around 24 weeks' gestation. While increasing survival has been the predominant driver leading to lowering the gestation at which care can be provided, these infants remain at significant risk of adverse long-term outcomes including neuro-developmental disability. Decisions about commencing and continuing intensive care are determined in partnership with parents, considering the best interests of the baby and the family. Occasionally, clinicians and parents come to an impasse regarding institution or continuation of intensive care. Inevitably, these ethical dilemmas need to consider the uncertainty of the long-term prognosis and challenges surrounding providing or withdrawing active treatment. Further reduction in the gestational age considered for institution of intensive care will need to be guided by short- and long-term outcomes, community expectations and the availability of sufficient resources to care for these infants in the neonatal intensive care unit and beyond.     

Does selective digestive decontamination prevent nosocomial infections?]

Paediatric intensive care and haematological units are ideal sites for the development of nosocomial infections. These infections remain a significant source of mortality and morbidity and increase length of stay and costs. Selective digestive decontamination (SDD) includes topical antibiotics during the entire intensive care unit (ICU) stay, parenteral antibiotic administered for three to five days, hand hygiene and surveillance cultures of throat and rectum. Its use is based on the observation that resistant bacteria are often imported by the patients themselves, and the fact that transmission via the hands of carers could be responsible only for infections occurring after one week. In adult patients, seven meta-analyses have demonstrated that SDD reduces the odds ratio for lower airway infections, and sometimes mortality (particularly in surgical and trauma patients). The main criticism against SDD is the possible emergence of antibiotic resistant bacteria, which is a growing problem in Europe and United States of America. Only four studies on SDD in children have been reported in the literature: due to methodological weaknesses and small size of samples, definitive conclusion cannot be drawn. However, one study in a 20 bed paediatric intensive care unit has demonstrated that SDD prevent both infections and the emergence of resistant bacteria. Furthermore, it has been demonstrated that more than 50% of children carrying resistant bacteria are detected within 24 hours of admission, suggesting that they import the resistant strains onto the intensive care unit. Factors that predict facility, administration of i.v. antibiotics within the past 12 months, previous intensive care unit admission and hospitalization of a household contact within the past 12 months. As suggested by several authors, the term selective should mean selection of appropriate patient groups (those at high risk of nosocomial infection, e.g. patients mechanically ventilated for at least 48 hours) and units (excluding those where multiresistance is endemic). Obviously, surveillance of patient and unit bacterial ecology and improvement of antibiotic policy must be reinforced.     

Parental visiting, communication, and participation in ethical decisions: a comparison of neonatal unit policies in Europe.

AIM: To compare neonatal intensive care unit policies towards parents' visiting, information, and participation in ethical decisions across eight European countries. METHODS: One hundred and twenty three units, selected by random or exhaustive sampling, were recruited, with an overall response rate of 87%. RESULTS: Proportions of units allowing unrestricted parental visiting ranged from 11% in Spain to 100% in Great Britain, Luxembourg and Sweden, and those explicitly involving parents in decisions from 19% in Italy to 89% in Great Britain. Policies concerning information also varied. CONCLUSIONS: These variations cannot be explained by differences in unit characteristics, such as level, size, and availability of resources. As the importance of parental participation in the care of their babies is increasingly being recognised, these findings have implications for neonatal intensive care organisation and policy.     

Acquired--accepted--adopted? On the status of neonatology in West Germany

The worldwide reduction in infant mortality and low birthweight lethality has also been observed in the Federal Republic of Germany during the past two decades. In many countries, neonatology has emerged as a scientifically active subspecialty of pediatrics. Its main characteristic is an understanding of partially mature function and perinatal adaptation. In West Germany, however, education programs for neonatologists have not been inaugurated and neonatology has been identified with pediatric intensive care. Sophisticated neonatal transport systems, expensive special care units, and highly aggressive therapeutic approaches have resulted. Neither perinatal centers for high-risk deliveries nor regionalization programs for intrauterine transport to the neonatal special care unit have been created. Neonatology may drift towards obstetrics if established pediatrics continues to ignore educational, organizational and manpower needs of neonatal care.     

Admission and discharge guidelines for the pediatric patient requiring intermediate care

During the past 3 decades, the specialty of pediatric critical care medicine has grown rapidly, leading to a number of pediatric intensive care units opening across the country. Many patients who are admitted to the hospital require a higher level of care than routine inpatient general pediatric care, yet not to the degree of intensity of pediatric critical care; therefore, an intermediate care level has been developed in institutions providing multidisciplinary subspecialty pediatric care. These patients may require frequent monitoring of vital signs and nursing interventions, but usually they do not require invasive monitoring. The admission of the pediatric intermediate care patient is guided by physiologic parameters depending on the respective organ system involved relative to an institution's resources and capacity to care for a patient in a general care environment. This report provides admission and discharge guidelines for intermediate pediatric care. Intermediate care promotes greater flexibility in patient triage and provides a cost-effective alternative to admission to a pediatric intensive care unit. This level of care may enhance the efficiency of care and make health care more affordable for patients receiving intermediate care.     

Supportive measures in aggressive cytostatic therapy

Over the past years significant progress has been made in the treatment of childhood cancers due to newer and more intensive chemotherapeutic regimes. However, with the increased intensity of chemotherapy, more treatment related complications are seen, requiring also more aggressive supportive care. The major complications of the cytotoxic treatment are bone marrow aplasia, immunosuppression, vomiting, anorexia and weight loss and supportive measures as adequate blood component supply, prophylaxis, recognition and effective treatment of infections as well as parenteral hyperalimentation are corner stones of modern cancer therapy. Blood sampling, application of blood products or intravenous drugs and continuous parenteral nutrition is easily performed using a central venous line. Our experience with the continuous venous access of central lines in patients receiving aggressive cytotoxic treatment did not show a higher incidence of infectious complications but had significant advantages in the supportive care.     

Outcome of paediatric intensive care survivors

The development of paediatric intensive care has contributed to the improved survival of critically ill children. Physical and psychological sequelae and consequences for quality of life (QoL) in survivors might be significant, as has been determined in adult intensive care unit (ICU) survivors. Awareness of sequelae due to the original illness and its treatment may result in changes in treatment and support during and after the acute phase. To determine the current knowledge on physical and psychological sequelae and the quality of life in survivors of paediatric intensive care, we undertook a computerised comprehensive search of online databases for studies reporting sequelae in survivors of paediatric intensive care. Studies reporting sequelae in paediatric survivors of cardiothoracic surgery and trauma were excluded, as were studies reporting only mortality. All other studies reporting aspects of physical and psychological sequelae were analysed. Twenty-seven studies consisting of 3,444 survivors met the selection criteria. Distinct physical and psychological sequelae in patients have been determined and seemed to interfere with quality of life. Psychological sequelae in parents seem to be common. Small numbers, methodological limitations and quantitative and qualitative heterogeneity hamper the interpretation of data. We conclude that paediatric intensive care survivors and their parents have physical and psychological sequelae affecting quality of life. Further well-designed prospective studies evaluating sequelae of the original illness and its treatment are warranted.     

Treatment choices for extremely preterm infants: an international perspective

OBJECTIVE: To compare treatment choices of neonatal physicians and nurses in 11 European countries for a hypothetical case of extreme prematurity (24 weeks' gestational age, birth weight of 560 g, Apgar score of 1 at 1 minute). STUDY DESIGN: An anonymous, self-administered questionnaire was completed by 1401 physicians (response rate, 89%) and 3425 nurses (response rate, 86%) from a large, representative sample of 143 European neonatal intensive care units. Italy, Spain, France, Germany, the Netherlands, Luxembourg, Great Britain, Sweden, Hungary, Estonia, and Lithuania participated. RESULTS: Most physicians in every country but the Netherlands would resuscitate this baby and start intensive care. On subsequent deterioration of clinical conditions caused by a severe intraventricular hemorrhage, attitudes diverge: most neonatologists in Germany, Italy, Estonia, and Hungary would favor continuation of intensive care, whereas in the other countries some form of limitation of treatment would be the preferred choice. Parental wishes appear to play a role especially in Great Britain and the Netherlands. Nurses are more prone than doctors to withhold resuscitation in the delivery room and to ask parental opinion regarding subsequent treatment choices. CONCLUSION: An extremely premature infant is regarded as viable by most physicians, whereas after deterioration of the clinical conditions decision-making patterns vary according to country. These findings have implications for the ethical debate surrounding treatment of infants of borderline viability and for the interpretation and comparison of international statistics.     

Outcomes after the Fontan procedure

Over the past two decades, advances in congenital heart surgery, pediatric cardiology, and intensive care medicine have dramatically increased the survival of infants with critical congenital heart disease. The group of patients that has perhaps benefited the most from this progress has been the single-ventricle population. Staged palliation culminating in the Fontan procedure has resulted in a decreasing mortality rate and an increase in the number of single-ventricle survivors. Over the past 18 months, many studies have focused on outcomes after the Fontan procedure. These reports demonstrate progressive improvement in early postoperative survival and intermediate and late postoperative outcomes due to surgical innovations, such as the lateral tunnel and extracardiac Fontan modifications, and fenestration, as well as technological improvements, such as modified ultrafiltration. Despite these improvements, significant morbidity remains after the Fontan completion, including myocardial systolic and diastolic dysfunction, systemic arterial and venous hemodynamic abnormalities, diminished exercise capacity, arrhythmias, protein-losing enteropathy, somatic growth retardation, neo-aortic valve root dilation and insufficiency, thromboembolic complications, and below-average cognitive development.     

Esophageal atresia with distal tracheo-esophageal fistula. Evolution of the treatment in the period of 1955-2000 at the Anna Meyer Children's Hospital of Florence

BACKGROUND: Over the past decades the esophageal atresia (EA) has represented the greatest challenging malformation encountered by the pediatric surgeon. Since then, there have been considerable advancements in the treatment of EA. In this paper the experience at the "Anna Meyer Children's Hospital of Florence" in regards to the surgical treatment of the EA from 1955 to present day is reported, so that the analysis of the various medical and surgical choices followed by the authors and their predecessors in this long period, can be an important learning tool for the EA management. METHODS: From 1955 to 2000, 223 newborns affected by EA with tracheoesophageal fistula (TEF) have been operated on out of a total of 250 cases of EA. Our experience has been subdivided into periods on the basis of homogeneous medical and surgical treatment adopted in that determined time. We have analyzed particularly the data of the last period 1995-2000, where there has been a well standardized protocol of treatment from the medical, surgical and intensive care points of view. RESULTS: The mortality rate has decreased from 44.8 to 3.4% with a significant reduction (p<0.001) between the years 1979-1983 and 1984-2000, due to the introduction of a perioperative treatment in the newborn intensive care unit. Moreover, a significant correlation (p<0.05) has been shown between low birthweight and associated malformations, two risk factors that however do not negatively influence the results of the treatment in the last period 1995-2000. CONCLUSIONS: A full integration between the surgeon and neonatologist is necessary in order to guarantee a good result. The risk connected to EA is not as much the surgical procedure as the presence or absence of associate malformations that are undetected in the prenatal diagnosis. It is suggested that, in order to further reduce the mortality and morbidity rate after EA correction, the number of prenatal diagnoses should be increased.     

Multiple trauma: liver and spleen injury

The management of hepatic and splenic injuries in childhood has evolved over the past 30 years from prompt operation upon recognition of injury to nonoperative management in the large majority of children. Many aspects of nonoperative management have become increasingly standardized and efforts continue to further refine this strategy. The appropriate intensive care unit and acute care unit length of stay, the number of laboratory draws, the length of activity restriction and the need for radiographic evidence of healing prior to release from activity restriction remain areas of study. Previously demonstrated variation in the management and outcome of injured children between adult and pediatric surgeons has led to debate over which type of facility should best care for injured children. The Pennsylvania Trauma Systems Foundation dataset was used to derive a series of children with severe liver injuries. Finally, the risk of post-splenectomy sepsis, a stimulus for the initial development of nonoperative management, has been further clarified by a literature review. While falls from a low height may infrequently lead to a significant injury, falls from greater heights are more likely to induce a solid organ injury.     

A short-term intensive training program for pediatric nurse practitioners.

A pediatric nurse practitioner course has been described in which 30 nurse trainees spent six seeks in an intensive training program followed by six months of preceptorship with a pediatrician in their own agency. This short but intensive program had advantages of permitting the PNP student to retain her health care agency position during the intensive part of the program and of assuring her a position as a PNP once the course was completed. Evaluation of the students by written and practical examinations indicated that they had made significant gains in their knowledge and understanding of pediatrics and in their ability to evaluate and refer patients and to provide well-child care and maternal counseling.     

Ethical issues in neonatal intensive care and physicians' practices: a European perspective

An international project (EURONIC) was carried out to explore the end-of-life decision-making process in a large, representative sample of neonatal intensive care units (NICUs) in eight western European countries: France, Germany, Great Britain, Italy, Luxembourg, the Netherlands, Spain and Sweden. Structured questionnaires were used to record data on NICU organization and policies, and to survey staff views and practices regarding ethical decision-making. One hundred and twenty-two NICUs were recruited by census or random sampling (response rate 86%); 1235 physicians and 3115 nurses completed the staff questionnaire (response rates 89 and 85%, respectively). This paper focuses on the physicians' answers. In all countries but Italy, most physicians reported having been involved at least once in setting limits to intensive care because of a baby's incurable condition and/or poor neurological prognosis. Adopted strategies varied between countries. Practices such as the continuation of current treatment without intensifying it and the withholding of emergency manoeuvres appeared widespread. In contrast, the frequency of doctors reporting withdrawal of mechanical ventilation was highest in the Netherlands (93%), Sweden (91%) and the Great Britain (88%), intermediate in France and Germany, and lowest in Spain and Italy (34 and 21%, respectively). CONCLUSION: Ethically problematic clinical cases are approached differently in the various countries. The findings of this study may provide an opportunity for physicians to review their practices critically, in light of how other colleagues proceed, and foster an open discussion about these difficult issues.     

Ethical issues in neonatal intensive care and physicians' practices: A European perspective

An international project (EURONIC) was carried out to explore the end-of-life decision-making process in a large, representative sample of neonatal intensive care units (NICUs) in eight western European countries: France, Germany, Great Britain, Italy, Luxembourg, the Netherlands, Spain and Sweden. Structured questionnaires were used to record data on NICU organization and policies, and to survey staff views and practices regarding ethical decision-making. One hundred and twenty-two NICUs were recruited by census or random sampling (response rate 86%); 1235 physicians and 3115 nurses completed the staff questionnaire (response rates 89 and 85%, respectively). This paper focuses on the physicians' answers. In all countries but Italy, most physicians reported having been involved at least once in setting limits to intensive care because of a baby's incurable condition and/or poor neurological prognosis. Adopted strategies varied between countries. Practices such as the continuation of current treatment without intensifying it and the withholding of emergency manoeuvres appeared widespread. In contrast, the frequency of doctors reporting withdrawal of mechanical ventilation was highest in the Netherlands (93%), Sweden (91%) and the Great Britain (88%), intermediate in France and Germany, and lowest in Spain and Italy (34 and 21%, respectively).
Conclusion: Ethically problematic clinical cases are approached differently in the various countries. The findings of this study may provide an opportunity for physicians to review their practices critically, in light of how other colleagues proceed, and foster an open discussion about these difficult issues.     

Impact of societal factors and health care delivery systems on gastroschisis outcomes

Care of infants with gastroschisis is associated with a significant burden on health care delivery systems. Mortality rates in patients with gastroschisis have significantly improved over the past few decades. However, the condition is still associated with significant short-term and potentially long-term morbidity. Significant variations in clinical outcomes and resource utilization may be explained by several factors including provider and hospital experience, level of neonatal intensive care, variations in hospital regionalization of care, and differences in healthcare delivery systems. Reviewing and assessing these hospital and healthcare system related factors are paramount in addressing variations in gastroschisis care and improving outcomes for these vulnerable infants.     

Inhaled nitric oxide during emergency neonatal transportation

ABSTRACT Inhaled nitric oxide is currently being investigated as a selective pulmonary vasodilator for neonates with persistent pulmonary hypertension. The use of continuous inhaled nitric oxide during emergency transportation of three critically ill neonates with meconium aspiration and pulmonary hypertension is described. The successful application of this technique may allow safer transportation of neonates who require high level intensive care including ongoing nitric oxide, high frequency ventilation and/or extracorporeal life support. Regionally based nitric oxide-equipped retrieval teams may relieve the pressure on smaller neonatal intensive care units to provide inhaled nitric oxide therapy and allow centralization of nitric oxide resources, thus facilitating development of expertise and the completion of meaningful research programs with substantial recruitment.